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2. 
4. Filing a complaint

   If your complaint/grievance involves a facility, program, or service owned and/or operated by the City of Grand Junction, continue to fill out the form below. 

   If the complaint/grievance does not apply to the above, contact the U.S. Department of Justice Information Line at 1-800-514-0301.

   The following information is needed to assist in processing your complaint/grievance. Please complete the form and either submit electronically or print, complete, and send to City of Grand Junction ATTN: Jordan Salazar, 250 N. 5th St., Grand Junction, CO 81501

8. Section 1. Contact Information
10. First Name*
11. Last Name*
13. Phone Number (Home or Cell)*
14. Address
16. City
17. State
18. Zip Code
20. Email Address
24. Section 2. Complainant Information
26. Are you filing this complaint on your own behalf?

    1. Yes
    2. No
28. If yes, skip to Section 3. If no, please provide the following contact information for the person discriminated against:
30. First Name
31. Last Name
33. Phone Number
34. Address
36. City
37. State
38. Zip Code
40. Email Address
44. Section 3. Incident Description
46. Date of the alleged discrimination:
    Date of the alleged discrimination:
48. Location of the alleged discrimination:
50. Explain as clearly as possible what happened and why you believe that you were discriminated against. Describe all of the persons, program and/or services involved. *
52. Please list any and all witnesses’ names and phone numbers/contact information.
54. Have you discussed your complaint with a City employee?

    1. Yes
    2. No
56. If yes, provide name(s) and position(s).
58. Have you filed your complaint with a federal, state, or local agency; or with a federal or state court?

    1. Yes
    2. No
60. Have you filed a complaint with any other federal, state or local agency or with any federal or state court? Check all that apply.

    1. Federal Agency
    2. Federal Court
    3. State Agency
    4. State Court
    5. Local Agency
62. You may attach any written materials or other information you think is relevant to your complaint.

    Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

64. By inputting my name below, I affirm that the above is true to the best of my knowledge, information, and belief.
66. Name*
67. Date*
    Date
Leave This Blank:


69. 1. Receive an email copy of this form.
70. Email address

    This field is not part of the form submission.

71. Submit

* indicates a required field